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NuEdge Distributor Questionnaire

To start the process of becoming an authorized distributor for NuEdge/Vizient, complete the following form. Please note that this does not guarantee your acceptance. You will be notified once approved/denied.
_{*Indicated required fields.}

Distributor Name^*

Contact Name^*

Address^*

City^*

State^*

Zip^*

Phone^*

Email^*

Geographic Coverage by State

Number of Distribution Centers

NDC Account Number

Distributor Minority Status

ERP System Software

Can your system manage rebate pricing?

Do you order electronically (EDI)?

Does your company have an NDC Contract Admin Agreement

Has your company used GPO Contract Pricing before?

Primary Customer Market Focus

If your company has a Contract Coordinator, please provide their contact information:

Name

Title

Please list all suppliers for whom you supply sales tracing data through NDC:

Please list all suppliers for whom you supply sales tracing data direct to the supplier:

Provide two current customer address details:

Customer 1

Name

Street Address

City

State

Zip

Customer 2

Name

Street Address

City

State

Zip

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